A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation.
At which location should the nurse expect to palpate the fundus?

1 cm below the umbilicus

3 cm below the umbilicus

2 cm above the umbilicus

3 cm above the umbilicus

Answer and Explanation

The Correct Answer is C

A. 1 cm below the umbilicus: This is too low for a client at 22 weeks of gestation.

B. 3 cm below the umbilicus: This is also too low for a client at 22 weeks of gestation.

C. 2 cm above the umbilicus: At 22 weeks of gestation, the fundus should be palpated about 2 cm above the umbilicus, which is at approximately the level of the maternal belly button.
D. 3 cm above the umbilicus: This is too high for a client at 22 weeks of gestation.

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Correct Answer is A

Explanation

Choice A: The first priority assessment finding to report to the provider is contractions lasting 2 minutes and with no rest between contractions. Prolonged contractions without adequate rest can lead to uterine hyperstimulation and fetal distress, potentially compromising the wellbeing of both the client and the baby. The provider needs to be informed immediately for further

evaluation and intervention.

Choice B: Pressure on the perineum and the desire to bear down indicate that the client is experiencing the urge to push, which is expected during the second stage of labor, not during the active phase of the first stage. It is not the first priority to report.

Choice C: Clear fluid discharge from the vagina can indicate rupture of membranes, but it is not an immediate concern unless the fluid is meconiumstained or there are other signs of fetal distress.

Choice D: Passage of a bloodtinged mucous plug (also known as "bloody show") is a common sign that labor is approaching, but it is not an immediate concern unless there are other signs of labor progression or complications. It is not the first priority to report.

A. Vomiting B. Tachycardia C. Hypotension D. Respiratory depression

Correct Answer is C

Explanation

A) Vomiting: Vomiting is not a common complication of epidural anesthesia. Nausea can occur but is not directly related to the epidural block itself.
B) Tachycardia: Tachycardia is not a common complication of epidural anesthesia. It may occur due to other factors, but it is not directly associated with the epidural block.
C) Hypotension: Hypotension (low blood pressure) is a common complication of epidural anesthesia. The epidural can cause vasodilation, leading to a drop in blood pressure. It is essential to monitor the client's blood pressure and intervene promptly if hypotension occurs.
D) Respiratory depression: Respiratory depression is not a typical complication of epidural anesthesia. Epidural anesthesia mainly affects the lower part of the body and does not usually cause significant respiratory effects.

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A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus?

A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation.
At which location should the nurse expect to palpate the fundus?